Paper vs. Electronic Records

If you had asked me ten years ago whether or not the entire medical/dental profession would be using electronic charts by now I would have said “yes”! However, ten years later I can now see paper records persisting for many years to come. Issues surrounding electronic medical/dental records go beyond concerns associated with bank accounts and credit card files. Health records can contain all of the private information important to financial files, with the addition of personal health information that can be even more sensitive. Privacy issues aside, electronic records also fall into the category of “may be very expensive to implement”. Despite this, most everyone agrees that eventually all health providers will be using digital records. It is primarily a matter of finding answers to several important concerns associated with digital charts.
What are some concerns regarding electronic records?
• As part of the American Recovery and Reinvestment Act, healthcare providers who install Electronic Health Records systems may receive monetary incentives. These incentives can range from $18,000 in the first year of EHR implementation, dropping to $12,000 if it occurs in 2014. Dentists are not explicitly named as “healthcare providers” in the Act’s definitions section. However, the barrier to receiving any government money seems to hinge less on definitions and more on the fact that only “certified” electronic health records products will qualify. Healthcare providers must use a product that has been certified by the Certification Commission for Healthcare Information Technology, a group that is responsible for certifying all E H R products in the United States. According to the communication manager for CCHIT “we have not gotten into dental yet, and it is not on the horizon.”
• Digitized records are currently not able to capture all the information a dental office needs to record. According to an article in the Journal of the American Medical Informatics Association, computerized records for dentists are difficult to navigate plus being incomplete. The “data fields” available for digital records average only 174 fields, versus 360 available with a paper record. The study is not that recent, being completed in 2000. Since that time many improvements have been made. However, the fact remains that while 85 percent of dentists use computers in their offices, only 2 percent maintain fully digitized records.
• Where is all the data on the electronic records going to reside? Will there be a computer bank? A server system? Will each office or hospital maintain a data file? According to HIPAA, one of its’ goals is to set up a national digitized system where providers and patients can access information utilizing confidential identifier numbers. The records themselves will reside on the Internet or in a yet to be developed health records bank. If a confidential “identifier” will be needed to access information, the National Provider Identifier numbers that dentists are currently using on electronic insurance claims will not be those identifiers. According to a mailing that I received in September of 2007, a national address label company that sells names and addresses of physicians and dentists, now can also provide the doctors’ NPI numbers!
• The George Clooney effect. Patient data that is maintained on a hospital site appears to be far from “safe”. When the actor George Clooney was injured last year in a motorcycle accident, the New Jersey hospital where he was treated later discovered (through a random audit) that at least two dozen employees had “snooped” into his record. Could they have snooped into a paper record? Of course! But a paper record stays “in-house” Once files are on a computerized system, there appears to always be someone, inside or outside, who can get past its’ security.
• The Octomom effect. According to Modern Healthcare magazine, May 2009, “California regulators have fined Kaiser Permanente Bellflower Medical Center $250,000 for failing to keep workers from looking at the electronic health records of Nadya Suleman. She is the mother of the octuplets born earlier this year. According to the complaint, twenty-three unauthorized staff and physicians accessed her medical records”, including some records that were “contained” at other Kaiser hospitals. The fine is a heavy one, but further penalties can include personal fines and even the loss of provider licenses! The upshot is that the harsh penalties may deter others from unauthorized access of health records, or they just may encourage future “peekers” to be more careful. After all, the National Enquirer pays well for such information.
• Computerized Physician Order Entry. CPOE, is said to be an important “goal” for acceptable electronic health records to satisfy government stimulus guidelines. (CPOE is apparently a less popular program feature in that many systems already in existence do not have it.) This poses several questions for dentistry. Would CPOE demand that the dentist herself make progress notes or other entries in a patient’s electronic health record? Would these notes have to be made at the time of service, later that day, tomorrow, next week? Would CPOE demand that prescriptions be forwarded on a direct electronic system to a pharmacy? Would that be the same thing as using a secure e-filing system based on e-mail?
• Electronic charts need to contain certain items in order to be considered complete, just as a paper based record does. According to the detailed and excellent “Process of Care Evaluation Measures” document, which was designed by Dr. D.E. Fitzgerald to provide a roadmap for objectively evaluating a record, these include but are not limited to:
 Medical histories and updates
 Dental history and chief complaint
 Existing conditions and pathology
 Periodontal status
 Soft tissue evaluation including cancer screening
 Treatment plan-per tooth and per case
 Informed consent
 Detailed progress notes

• Finally, the cost of electronic systems can be high. To be effective, a digitized patient record should be integrated with the rest of the practices’ software. This can be expensive, and as we have learned, there is currently no stimulus money available for the software packages available to dentistry.

Regardless of whether an office is using the most elaborate electronic record imaginable, or a detailed paper chart, the purpose of the patient’s visit is not to create a record. The record is created to verify and document the patient’s care. While I have a bias as the creator of a paper record system which is in use in thousands of offices nationwide, eventually the issues surrounding digitized charts will be solved. In the meantime, the choice does not have to be between an expensive digitized format or an inadequate “brown envelope” chart. A third choice is available. Offices who would like to take a look at a paper chart that fulfills the requirements of a proper record inexpensively should go to my website at www.steppingstonestosuccess.com, and click on the First Encounter Chart™. I can also send you a complimentary sample. An electronic chart may be in your future, but an inexpensive, detailed, accurate and appropriate patient record is available now.

Disclosure: Carol Tekavec CDA RDH is the designer of a paper based patient record which she uses in the courses she provides for the ADA Seminar Series.

Author bio: Carol Tekavec CDA RDH is the president of Stepping Stones to Success, a Consultant to the ADA Council on Dental Practice, and a practicing dental hygienist. You can contact her at 800-548-2164, or email carol@steppingstonestosuccess.com.

Thanks for all the comments! Dr. Pruitt, it appears that you have taken a great deal of time in researching record keeping issues. Thanks for weighing in. It is a dilemma for us all. As they say, "stay tuned". Carol

What a wonderfully frank comment, Carol Tekavec! I hold special respect for those like you who have the courage to go against the popular grain of feel-good, politically-correct superstitions like those that surround the untested promises of electronic dental records. There aren’t many of us who see through the fantasy and speak up for the safety of our patients… yet. Our patients’ safety is what it is all about, isn’t it?

It is indeed refreshing to hear someone of national credibility, as well as a respected consultant to the ADA’s Council on Dental Practice, say that “…the purpose of the patient’s visit is not to create a record.”

I too am afraid there are far too many, far too enthusiastic HIT cheerleaders, even in the leadership of the ADA, who think high-tech EDRs are the goal and information the tool. Let’s face it. We both know that not only do interoperable records present bankruptcy-level liabilities for dentists in the event of a breach, but they seriously threaten the welfare of our patients for trivial, I repeat, trivial gains for everyone except those who would use digitalization to commandeer the care we provide to our trusting patients (such as Delta Dental, BCBS and Newt Gingrich).

Have you yet been called a “Luddite”? I have. Several times, actually. I’ve discovered that heavily invested HIT cheerleaders can be sensitive about constructive, blunt criticism - especially the anonymous ones. I’ve also been called a flat-Earther and a butt. These days, I turn the other cheek… hard.

Whereas the telephone, fax and US Mail are safe as well as adequate for dentists’ communication needs, interoperability for physicians is necessary for efficient communications between specialists and for quickly assembling imagery and lab test results. But even so, a week ago an article posted on allheadlinenews.com revealed that in Canada, after 8 years of effort and spending $1.6 billion, only 17% of MDs have adopted eMRs.
http://www.allheadlinenews.com/articles/7015579435

In Great Britain, even more money and time was wasted on a fanciful system that the NHS essentially scrapped a year ago because of their dismal luck at success. So what do American MDs think about the CMS stick and carrot idea to stimulate adoption? If you hadn’t heard, MDs are in open rebellion - just like the ADA might have been 6 years ago if our ADA leaders in charge of the Department of Dental Informatics weren’t so power-hungry that they failed to recognize absurdity. Did I mention that compared to eMRs, which have negative value in the free market, eDRs are even more worthless?

According to an article posted in the amednews.com posted today, the AMA House of Delegates told CMS to take a hike. “Physician-delegates at the AMA Annual Meeting in June formally came out against planned penalties included in this year's federal stimulus bill that would dock Medicare pay for physicians who do not have a qualifying electronic health record.”
http://www.ama-assn.org/amednews/2009/06/29/prsd0629.htm

Just who does CMS think they’re dealing with? The leaders of the AMA are nothing like the ADA pushovers who so desperately want to get along with everyone - even if it means needlessly endangering dental patients.

I looked up “Luddite.” The Luddites were textile artisans in a doomed British social movement in the nineteenth century when the manual weavers protested against industrialization. They often destroyed the mechanized looms which replaced their tedious art work. As anyone can see, “Luddite” is hardly an accurate label for those like us who urge caution in adoption of eDRs. If a computer takes over all of my record keeping, it still will not replace my intricate art done in unpredictable environments to exacting tolerances. In addition, rapid production of mechanized, uniform bolts of cloth is desirable, but no two teeth and no two patients are the same.

Here’s another difference: Which is more likely to entangle and harm an innocent person in the fast-moving parts of complicated, untried technology - a hand loom or computerized dental records?